Neck Trauma Objectives At - PowerPoint Presentation

Slide1

Slide2

Neck Trauma

Slide3

Objectives

At

the conclusion of this presentation the participant will be able to:

Examine the spectrum of neck trauma, the mechanisms of injury and associated injury patterns

Define the three zones of the neck used as classifications of injury

Identify the appropriate diagnostic modalities used to evaluate patients with neck trauma

Explain the therapeutic interventions in the management of neck trauma

Identify nursing interventions important in

caring for patients with neck trauma

Slide4

Epidemiology

3500 deaths per year

Mortality rate 2-6%

Blunt mechanism accounts for 5%

Penetrating trauma accounts for most

Zone I injuries are the most lethal

Slide5

Epidemiology

Commonly injured vessels

Internal jugular vein

Internal carotid artery

Laryngeal and tracheal more common than pharyngeal and esophageal injuries

Slide6

Blunt Mechanism of Injury

Steering wheel

Assault

Strangulation/Hanging

“Clothes line” injuries

Other (sports, industrial, etc.)

Slide7

Penetrating Mechanism of Injury

Missile injury (bullet, knife, or other)

Stabbing or lacerations

Impalement

Animal bites

Slide8

Anatomical Review

Fascia

Deep cervical fascia

Superficial fascia

Slide9

Structures at Risk

Musculoskeletal

Vertebral bodies

Cervical muscles and tendons

Clavicles, 1

st

and 2

nd

ribs

Hyoid bone

Glandular

Thyroid

Parathyroid

Submandibular

Parotid glands

Slide10

Anatomical Review

Slide11

Structures at Risk

Visceral structures

Thoracic duct

Esophagus

Pharynx

Larynx

Trachea

Slide12

Structures at Risk

Slide13

Structures at Risk

Slide14

Zones of the Neck

Zone III -

Clavicles and sternal notch to cricoid cartilage

Zone II –

Cricoid cartilage to the angle of mandible

Zone I –

Angle of mandible to base of skull

III

II

I

Slide15

Zones of the Neck

Zone I

Zone II

Zone III

Slide16

Zone I

Subclavian vessels

Brachiocephalic veins

Common carotid arteries

Aortic arch

Jugular veins

Esophagus

Lung apices

C- spine/cord

Cranial nerve roots

Slide17

Zone II

Carotid and vertebral arteries

Jugular veins

Pharynx

Larynx

Trachea

Esophagus

C-spine/cord

Slide18

Zone III

Salivary and parotid glands

Esophagus

Trachea

Vertebral bodies

Carotid arteries

Jugular veins

Cranial Nerves IX-XII

Slide19

History and Physical

Slide20

History and Physical

Gun

Caliper, distance

Knife

Length, angle

Amount of blood loss

Baseline mental status

Baseline motor status

Drug or alcohol use

Slide21

Key Findings

Hard signs

Airway obstruction

Pulsatile bleeding

Expanding hematoma

Unresponsive to resuscitation

Extensive subcutaneous emphysema

Soft signs

Voice change

Wide mediastinum

Hemoptysis

Hematemesis

Dysphonia/dysphagia

Slide22

Management - Primary Survey

ABCs

Ensure airway is patent

Ensure patient is adequately oxygenating

Control any obvious hemorrhaging

IV access

Slide23

Airway Considerations

Who requires immediate intubation?

Apneic

Comatose

Respiratory compromise

Expanding neck hematoma

Massive subcutaneous emphysema

Massive bleeding in airway

Slide24

Airway Considerations

“Wait and See”

Avoid excessive bag-valve-mask

Exercise caution with paralytics and sedation

Surgical airway last resort

Cricothyrotomy vs. tracheostomy

Slide25

Control Bleeding

Local pressure only

No

tourniquets

No

pressure dressings

No

probing or blind clamp placement

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Slide26

Physical Exam

Violation of the platysma muscle

CNS exam

Obvious hematoma, bleeding

Slide27

Physical exam

Contusions, lacerations, abrasions to the neck, etc.

Expanding hematomas, obvious bleeding

Hoarseness, stridor,

Subcutaneous emphysema

Hemoptysis, drooling

Dyspnea

Distortion of the normal anatomic landmarks

Mandibular/midface instability

Slide28

Diagnostic Studies

Chest radiograph

CT and CT angiogram

Laryngeal injury

Tracheal injury

Vessels

Blunt esophageal injury

Slide29

Diagnostic Studies

CT

S

can

Can

aid in identifying weapon trajectory and structures at

risk

Should only be used in stable

patients

Gracias

et al

(2001) found that use of CT scan in stable patients

Saved

patients from arteriogram indicated by

older

protocols 50% of the

time

Avoided

esophagoscopy in 90% of

patients

who might otherwise have undergone

it

Slide30

Diagnostic Studies

Laryngoscopy

Bronchoscopy

Esophagoscopy; esophagram

Rigid vs. flexible esophagoscopy

Color flow doppler, duplex ultrasonography

MRA

Slide31

Diagnostic Studies

Arteriogram

Gold standard

Invasive

C

omplications

Availability varies

Expensive

Contrast load

Simultaneous intervention

Slide32

Specific Injuries

Vascular

Aerodigestive

Cranial nerves

Thoracic duct

Slide33

Vascular Injuries in the Neck

Physical Exam

External marks

Decreased LOC

Hemiparesis

Hematoma

Hypotension

Dyspnea

Thrill, bruit, pulse not present

Slide34

Associated Injuries

Le Fort II or III fractures

Basilar skull fracture involving the carotid canal

Diffuse Axonal Injury with GCS < 6

Cervical vertebral body fracture

Near hanging with anoxic brain injury

Seatbelt abrasion of anterior neck with significant swelling/altered mental status

Slide35

Primary Diagnostics

CT angiogram of the neck

Chest x-ray indicated in Zone I injuries because of their proximity to the chest

Complete blood count, basic metabolic panel, toxicology and blood alcohol content

Slide36

Primary Diagnostics

Slide37

Vascular Injury Management

Common carotid: repair preferred over ligation in almost all cases

Internal carotid: Shunting is usually necessary

Vertebral: Angiographic embolization or proximal ligation can be used if the contralateral vertebral artery is intact

Internal Jugular: Repair vs. ligation

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Carotid Intimal Flap

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Carotid Artery Interposition Repair

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Management Summary

Vascular Injury

Surgical exploration unstable and stable Zone II

Angiography for Zone I and III

Selective, nonoperative management stable Zone II

Embolization high carotid or vertebral artery

Endovascular stent (pseudoaneurysms)

Anticoagulation blunt carotid/vertebral artery

Slide41

Aerodigestive Injuries

Airway structures

Trachea

Larynx

Thyroid cartilage

Esophagus

If diagnosis < 24 hours

Poor outcome if diagnosed > 24 hours

Pharyngeal

Slide42

Tracheal and Laryngeal Injuries

Signs of injury

Hoarseness and dysphonia

Hemoptysis

Subcutaneous emphysema in the neck and trunk

Tenderness over the trachea

Slide43

Primary Diagnostics

Laryngotracheal Injury

Plain x-rays

Soft tissue emphysema

A

irway compression

F

racture of laryngeal cartilages

CT scan

3D reconstruction

Endoscopy

Flexible vs. rigid

Bronchoscopy/laryngoscopy

Teeth

Cervical Spine

SubQ air

Slide44

Management

Laryngotracheal Injury

Secure the airway

Early repair

Laryngeal fractures

T

hyroid fracture most common

Delay of reduction makes it more difficult and return of normal function unlikely

Slide45

Esophageal Injury

Penetrating

Sharp weapon (knife)

High speed projectile (bullet)

I

atrogenic laceration

Lumen outward injury

Slide46

Esophageal Injury

Blunt

Barotrauma

Blast injuries

Crush injuries

Blow to the neck

Slide47

Esophageal Injury

Signs of Injury

Hematemesis

Odynophagia

Dysphagia

Drooling, hypersalivation

Tracheal deviation

Sucking neck wound

Subcutaneous emphysema

Pain with turning neck

Slide48

Esophageal Injury Diagnostics

Radiographic Findings

Plain films

Air in soft tissue planes

Pneumomediastinum

Leakage of fluid into right pleural space

Contrast swallow

Extravasation is

diagnostic

CT scan

Laboratory Findings

Markers of inflammatory response

Leukocytosis with left shift

Low oxygen saturations

Acidosis on ABG

Slide49

Esophageal Injury Diagnostics

Helical CT

E

xpedites diagnosis

Trajectory of missile

Associated injuries

Slide50

Diagnostics Esophageal Injuries

Normal

Thoracic Leak

Slide51

Esophageal Injury

Management Summary

Initial assessment complex

Goal is to minimize the bacterial contamination and enzyme erosion

Gastric decompression

Antibiotic coverage

Drainage of wound

Surgical repair

Slide52

Pharyngeal/Oral Injury

Similar presentation as esophageal injury

Slide53

Practice Guidelines

Few published practice guidelines for the management of neck injuries

Eastern Association for the Surgery of Trauma (EAST)

Penetrating neck injuries only

Blunt cerebrovascular injury

Slide54

EAST Guidelines Key Points

Selective operative management vs. mandatory exploration

CT Angiography and duplex ultrasound can be used to identify Zone II arterial injuries

Plain CT of the neck can be used to rule out a significant vascular injury

Contrast esophagography or esophagoscopy can be used to evaluate for perforation.

Serial

physical

examination is

95% sensitive for detecting arterial and aerodigestive tract injuries that need repair

Slide55

EAST Guidelines Summarized

Selective management is common now in asymptomatic patients;

CT angiography is a very good tool to rule out vascular injuries

The role of physical exam, esophagography, and esophogoscopy remains controversial

Slide56

Do all patients have to lay flat?

Position patient in manner that is most comfortable

Patients with anterior neck trauma may want to lean forward or sit upright

Patients with copious secretions can be rolled on their side

Slide57

Possible Complications

Loss of airway

Swallowing problems with aspiration

Stroke in unrecognized vascular injuries

Soft tissue necrotizing infections, including mediastinitis due to delayed diagnosis of esophageal injuries

Air embolism

Pneumothorax, tension pneumothorax

Slide58

Nursing Considerations

Be alert for:

Mental status changes and motor deficits

Changes in airway patency

Onset of stridor, drooling

Difficulty laying supine

Other injuries that are highly associated with cerebral vascular injuries

Slide59

Nursing Assessment

Frequent neurologic and motor checks

Frequent assessment for expanding hematomas in the neck

Careful history documentation

Reassurance

Adequate pain assessment

Anxiety reduction

Slide60

Summary

Penetrating and blunt neck trauma occurs in 5-10% of patients with serious injuries

Maintenance of an adequate airway is paramount to survival

Maintain a healthy respect for initially benign appearing injuries

Unrecognized vascular or aerodigestive injuries have a high mortality